SOW Attachment 06 - PIV Request Form.docx
DOCX document 134 KB Posted
- Attached to
- Z1DA--402-23-102, Medical Gas System Upgrade
- Solicitation number
- 36C24123R0150
About this file
This document is a form for requesting a Personal Identity Verification (PIV) badge to access the Department of Veterans Affairs (VA) Maine Healthcare System facilities in Augusta, Maine. The form requires applicants to provide their full name, physical address, gender, company affiliation, date of birth, place of birth, occupation, and personal email address. It must be filled out for individuals applying for either a PIV or non-PIV badge and submitted along with a full social security number. The form is also to be completed by engineers and requires the contract end date. It will be reviewed by the VA Maine Healthcare System Police Department and applicant records will be checked through the VA's own systems as well as local and federal databases to determine eligibility. Issuance of a badge is contingent upon submission of all requested information.
The related federal contract opportunity is a solicitation issued by the VA Veterans Health Administration Veterans Integrated Service Network 1 to upgrade the medical gas system. Solicitation number 36C24123R0150 has a title of Z1DA--402-23-102, Medical Gas System Upgrade. The opportunity type is a solicitation and work will be carried out within the agency of the Department of Veterans Affairs. No further details are provided on requirements, response dates, or award information.
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Text version
| Project Name: | _______________ | Type of Badge Requested: | PIV NON-PIV FLASH | |
| Circle one |
Department of Veterans Affairs VA Maine Healthcare System Police Department 1 VA Center 07B Augusta, ME 04330 207 623-5796
Individual applying for Badge must fill out this form with all highlighted information supplied and must call in Full Social Security number to 207 623-8411 ext. 5285. If this is not followed Badge cannot be processed.
Last Name First Name Middle (if no middle name please state NMI)
Physical Street Address City State and Zip Code
Gender (M) (F)
Service Line or Company Name Company or Cell Phone Number
Date of Birth
Place of Birth Occupation Title
Personal email for activation of badge process________________________________________________________
For Engineers to fill out:
Contract end date:_______________________________________________ Service Line Official Date
All highlighted info must be submitted, or a badge cannot be issued
FOR TOGUS POLICE USE ONLY
VISTA RECORDS:
DATE CHECKED BY RECORDS FOUND TYPE
VAPS RECORDS:
DATE CHECKED BY RECORDS FOUND TYPE
LOCAL RECORDS:
DATE CHECKED BY RECORDS FOUND TYPE
STATUS F YES NO ADVANCED TO HR
A MEMBER OF THE VA NEW ENGLAND HEALTHCARE SYSTEM
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File details come from the government source that posted it. Updated .